Dental limitations and exclusions.
1) Restorations, splints or other appliances used to increase vertical dimension or restore occlusion.
2) Splints or appliances used in the treatment of tempromandibular disorders.
3) Hospital benefits for any dental services.
4) Services that cannot be performed because of the general health, physical or psychological limitations of the patient.
5) Services for injuries or conditions which are covered under Worker’s Compensation or Employer’s Liability laws.
6) General anesthesia and moderate sedation
7) Periodontics, endodontics, periodontics or oral surgery requiring services of a provider outside the participating office. I.E. Referral to an outside specialist.
8) Procedures associated with full mouth rehabilitation to alter, maintain or restore the occlusion.
9) Diagnosis and treatment of myofacial pain dysfunction.
10) Procedures performed in a hospital.
11) Members may not participate in any other dental benefits/plans/coverage.
12) Non-compliance with recommended treatment may result in cancellation of membership.
13) Any dental procedure in progress or performed prior to enrollment in the membership is excluded.
14) Cost of dental care which are covered under automobile medical claims.
15) Replacement of lost or stolen bridgework or appliances is excluded.
16) Any procedure not listed as a covered service, including but not limited to emergency dental visits, prescription medication, etc is excluded.
17) Treatment to correct congenital, developmental, or medically induced dental disorders is excluded.
18) Bridges, crowns, dentures or any other prosthetic device or appliance requiring multiple treatment dates or fittings if the prosthetic item is inserted or delivered more then 60 days after the termination of the plan.
19) Dental implants
20) Endodontic therapy completed after the termination of the plan
21) replacement of sound restorations
22) Treatment of injuries sustained while practicing for or competing in an athletic sport of any kind
23) Treatment of any intentionally self inflicted injury/injuries, civil disobedience or criminal act
24) Replacement of complete or partial dentures, crowns or fixed bridgework due to patient negligence or non-compliance of their oral health and failure to abide by the recommended maintenance schedule of the provider.
25) Any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis
26) Preventive control programs
27) Treatments that are still under investigation or observation
28) Consultations or second opinions
29) Habit breaking appliances
30) Brushing and flossing instructions, tobacco and nutritional counseling
Orthodontic limitations and exclusions.
1) Any orthodontic procedure that began prior to membership.
2) Lost or broken appliances.
3) Loose, broken or lost brackets and bands.
4) Member relocation and is unable to continue care from the participating dentist then coverage of this plan will be terminated and it becomes the obligation of the member to pay the usual and customary fee to the new provider completing the treatment.
5) Accidents occurring during treatment.
6) Surgical orthodontic treatment.
7) Extractions require for orthodontic treatment.
8) Orthodontic treatment for the correction of Tempromandibular Disorders/Disfunction.
9) Additional fees may be applied to gross and non-cooperation by the member during treatment.